A nurse is caring for a client who has AIDS. The client states, “My mouth is sore when I eat.” Which of the following instructions should the nurse provide?

Choice A reason: Reassuring the client about future children minimizes her current grief and loss, which is inappropriate during initial grieving. This dismisses the emotional significance of the stillbirth, potentially causing distress, making it an insensitive and incorrect action.
Choice B reason: Discouraging friends from seeing the newborn restricts the client’s support system and grieving process. Allowing such interactions can provide closure and comfort, so this action is counterproductive and insensitive, making it incorrect for supporting grief.
Choice C reason: Offering to take pictures of the newborn provides a tangible memory, supporting the client’s grieving process. This sensitive intervention validates the loss and aids emotional healing, aligning with best practices for stillbirth care, making it the correct action.
Choice D reason: Advising against discussing the stillbirth isolates the client and hinders grief processing. Open communication with family fosters support and healing, so this action is harmful and contradicts grief support principles, making it incorrect.

Choice A reason: Removing restraints immediately risks safety, as the client’s calm state may not be sustained. Restraints require gradual removal after ensuring sustained behavioral stability, per facility policy and safety standards. Frequent monitoring is needed to assess ongoing safety, making this action premature and potentially unsafe.
Choice B reason: Encouraging group therapy is inappropriate while the client remains in restraints, as it does not address the immediate need to evaluate their behavior for safe restraint removal. Therapy may be beneficial later, but ongoing monitoring is the priority to ensure safety and compliance with restraint protocols.
Choice C reason: Continuing to monitor the client every 15 minutes ensures safety while assessing sustained calm and cooperative behavior. This adheres to restraint protocols, which require frequent checks to evaluate the need for continued restraint, prevent complications, and plan for safe removal, making it the correct action.
Choice D reason: Administering a sedative to maintain calm behavior is inappropriate without a current medical order or ongoing aggression. Sedatives carry risks like oversedation or respiratory depression. Monitoring the client’s behavior is the priority to determine if restraints can be safely discontinued, making this action unnecessary and potentially harmful.